In handing down his findings on the conduct of authorities in the December 2014 Lindt cafe siege, New South Wales coroner Michael Barnes was critical of the contribution of the psychiatrist (name suppressed) retained by NSW Police as an adviser at the scene. Among the criticisms of the psychiatrist’s actions that night, was that he provided flawed advice on the management of the siege that had a malign influence in tactical decisions that were instrumental to the tragic conclusion. The media coverage of this aspect of the coroner’s findings emphasises the psychiatrist as being hopelessly out of his depth and over-stepping his remit.
The psychiatrist involved is a well-respected and highly experienced physician, whose clinical skills, professional judgement and ethical practice are without question. This situation was not, in any way, a case of a bumbling incompetent out of his depth. It is, however, a spectacular illustration of the culture’s unhealthy idealisation of psychiatry’s capacity to predict and, ultimately, mitigate risk.
By all accounts, the perpetrator of the Lindt cafe siege was a narcissistic psychopath with an extensive criminal history. People with such severe personality disorders are often dangerous and unpredictable in their behaviour and psychiatry seldom has much to offer them. To many, the construct of narcissistic and antisocial personality “disorder” is little more than the medicalisation of criminality, much in the tradition of the criticisms of psychiatry made by the late Thomas Szasz.
Because such people are categorised as having a “disorder”, they are often deferred away from the criminal justice system into mental health services. With this comes the expectation that psychiatric treatment will modify the “risk” these people pose to the community. This creates a situation of medical practitioners being tasked with dealing with dangerous and violent criminals, whose bad behaviour is not an illness. The vast majority of people who seek psychiatric treatment, however, do not fall into this category.
In mainstream clinical practice, psychiatrists are also expected to predict and prevent the extremely rare instances of dangerous behaviour perpetrated by their patients. In the overwhelming majority of cases, it is people living with severe and persistent mental illnesses who are victims of violent crime. Psychiatrists are empowered by mental health laws to detain and enforce treatment on people suffering severe mental illness in a process that, at least in Australia, has disturbingly limited judicial oversight. “Risk” becomes the main focus of the exercise of such laws and, inevitably, the organising principle of treatment. In this context, the ultimate goal of involuntary psychiatric treatment is to render people with mental illness less dangerous — not relieve their suffering or improve their quality of life.
The over-endowment of psychiatrists with the power of risk prediction and prevention of danger interrogates the concept of “manufactured risk” first described in the 1980s by sociologist Anthony Giddens. In a “modern” society, it is held that man-made risk, such as that emerging from mental illness, can be apprehended and modified. Any failure to do so is judged harshly. Every suicide is assumed preventable, every act of violent madness foreseeable.
Psychiatry has an important place in society. It has brought relief to countless troubled souls and has, in many instances, been a positive influence on the culture. On the night of December 14, 2014, my colleague was placed in an extraordinary position and endowed with powers of prediction he did not (nor would he have claimed to) have. If authorities over-interpreted his advice and made poor decisions in that context, the critical analysis should now be of a culture that expects that the inherent risk of every aspect of life can be assessed and neutralised.
*Michael Robertson is a clinical associate professor of mental health ethics at the Centre for Values, Ethics and the Law in Medicine, School of Public Health, University of Sydney